Statement on malignant mesothelioma in the United Kingdom

+ Mesothelioma should be considered in any patient with either pleural fluid or pleural thickening, especially if chest pain is present. + Mesothelioma may occasionally present with persistent unexplained chest pain and a normal chest radiograph. + Symptomatic metastatic disease is unusual at presentation. + The disease is inexorably progressive except in the few patients who have undergone curative surgery. PROGNOSIS + Median survival is poor, varying from 8 to 14 months in diVerent studies, similar to other types of lung cancer. + Epithelioid tumours have a better than average prognosis. DIAGNOSIS + The importance of a detailed occupational history cannot be overemphasised. + Any patient in whom mesothelioma is suspected should be promptly referred to a respiratory physician for further assessment. + Pathological confirmation of the diagnosis is recommended, unless the patient is frail or has extremely advanced disease. + Negative pleural biopsy and cytology results do not exclude mesothelioma and should lead to further investigation. + CT scanning plays a key role in the diagnosis of mesothelioma. Diagnostic imaging + CT scanning should be performed on all patients with undiagnosed pleural exudates. + Pleural plaques are indicators of asbestos exposure but are absent in many proven cases of mesothelioma attributable to asbestos fibre. + Demonstration of chest wall invasion by either CT scanning or MRI is highly suggestive of malignant rather than benign pleural disease. Pathological diagnosis + Pleural fluid cytology and histology of blind biopsy specimens have low diagnostic yield for mesothelioma but are important initial steps in diVerential diagnosis. + Ultrasound and CT guided biopsy and thoracoscopic and surgical biopsy techniques should be used to increase the likelihood of accurate diagnosis. + Pathologists should attempt to specify the histological type of mesothelioma. + A selection of special stains should be used to help diVerentiation of mesothelioma and pleural adenocarcinoma. TREATMENT STRATEGY + Staging is essential for correct selection of patients for surgery. + Staging provides important prognostic information. + Staging should be undertaken before clinical trials. RADICAL SURGERY + There are no randomised control trials to establish the role of radical surgery. + Radical surgery should only be considered when there is a positive diagnosis of epithelioid mesothelioma. + Surgery should only be performed in centres where there is an interest and experience in performing extrapleuropneumonectomies. + The limited evidence available has reported surgical results only as part of a multimodality treatment strategy. MANAGEMENT OF PLEURAL EFFUSIONS + Talc pleurodesis is probably the treatment of choice for the control of pleural fluid. + VATS pleurectomy is an eVective treatment to control pleural fluid in mesothelioma and is much safer than open pleurectomy and decortication. + The value of pleuroperitoneal shunts remains uncertain. RADIOTHERAPY + Prophylactic radiotherapy reduces chest wall implantation following invasive procedures. + Palliative radiotherapy provides pain relief in about half of all patients. + Palpable masses respond to radiotherapy in about half of all patients. + Breathlessness and superior vena caval obstruction rarely respond to radiotherapy. CHEMOTHERAPY + All patients with mesothelioma should have the opportunity to discuss the pros and cons of chemotherapy with either an oncologist or respiratory specialist. + There are no published randomised trials comparing either survival or symptom control in patients treated with chemotherapy or best supportive care.